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Zhao Y, Chen S, Xie W, Zhang X, Chen G, Ji F, Wang D, Qi Y, Jie Q, Su D, Yu W. Efficacy and safety of adamgammadex for reversing rocuronium-induced deep neuromuscular blockade: A multicenter, randomized, phase IIb study. Clin Transl Sci 2024; 17:e13691. [PMID: 38266059 PMCID: PMC10785706 DOI: 10.1111/cts.13691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 10/10/2023] [Accepted: 10/21/2023] [Indexed: 01/26/2024] Open
Abstract
The rapid reversal of deep neuromuscular blockade (NMB) is important but remains challenging. This study aimed to evaluate the efficacy and safety of adamgammadex versus sugammadex in reversing deep rocuronium-induced NMB. This multicenter, randomized, phase IIb study included 80 patients aged 18-64 years, American Society of Anesthesiologists (ASA) grade 1-2, undergoing elective surgery under general anesthesia with rocuronium. Patients were randomized to the adamgammadex 7, 8, and 9 mg/kg group or the sugammadex 4 mg/kg group. The primary efficacy variable was the time to recovery of train-of-four ratio (TOFr) to 0.9. The secondary efficacy variables were the time to recovery of TOFr to 0.7, antagonistic success rate of the recovery of TOFr to 0.9 within 5 min, and incidence rate of recurarization within 30 min after drug administration. The explorative efficacy variable was the time to recovery of the corrected TOFr to 0.9 (actual/baseline TOF ratio). Adamgammadex 7, 8, and 9 mg/kg and sugammadex 4 mg/kg groups did not significantly differ in all efficacy variables. Importantly, adamgammadex 9 mg/kg permitted reversal within a geometric mean of 2.9 min. According to the safety profile, adamgammadex achieved good tolerance and low incidence of drug-related adverse events compared with the 4 mg/kg sugammadex. Adamgammadex 7, 8, and 9 mg/kg facilitated rapid reversal of deep rocuronium-induced NMB and had good tolerance and low incidence of drug-related adverse events. Therefore, adamgammadex is a potential and promising alternative to sugammadex.
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Affiliation(s)
- Yanhua Zhao
- Department of Anesthesiology, Ren Ji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Sifan Chen
- Department of Anesthesiology, Ren Ji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Wenqin Xie
- Department of AnesthesiologyQuanzhou First Hospital Affiliated to Fujian Medical UniversityQuanzhouChina
| | - Xiaoqing Zhang
- Department of AnesthesiologyTongji Hospital of Tongji UniversityShanghaiChina
| | - Guozhong Chen
- Department of AnesthesiologyThe 900 Hospital of the Chinese People's Liberation Army Joint Logistic Support ForceFuzhouChina
| | - Fuhai Ji
- Department of AnesthesiologyThe First Affiliated Hospital of Soochow UniversitySuzhouChina
| | - Dongxin Wang
- Department of AnesthesiologyPeking University First HosptialBeijingChina
| | - Youmao Qi
- Hangzhou Adamerck Pharmlabs IncHangzhouChina
| | - Qing Jie
- Hangzhou Adamerck Pharmlabs IncHangzhouChina
| | - Diansan Su
- Department of Anesthesiology, Ren Ji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Weifeng Yu
- Department of Anesthesiology, Ren Ji HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
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Gonzalez-Estrada A, Carrillo-Martin I, Morgenstern-Kaplan D, Garzon-Siatoya WT, Renew JR, Hernandez-Torres V, Volcheck GW. The Nonirritating Concentrations of Neuromuscular Blocking Agents and Related Compounds. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:466-473.e5. [PMID: 36108924 DOI: 10.1016/j.jaip.2022.08.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Skin testing (ST) concentrations of neuromuscular blocking agents (NMBAs), NMBA-reversal agents, and the sugammadex-rocuronium inclusion complex (S-R-Cx) vary widely among reports. OBJECTIVE To determine maximal ST nonirritant concentrations (NICs) of NMBAs (cisatracurium, rocuronium, succinylcholine, and vecuronium), NMBA-reversal agents (neostigmine and sugammadex), and S-R-Cx in NMBA-tolerant and NMBA-naïve participants. METHODS A single-center, prospective study between October 2019 and November 2021 of adult participants with or without a planned surgical procedure. The reference standard was tolerance of medication tested during a procedure (NMBA-tolerant group) before ST. Participants received skin prick testing (SPT) and intradermal test (IDT) injections at 5-7 increasing concentrations of 1 or more medications. All medications were reconstituted according to package insert instructions and diluted with 0.9% saline. A concentration was considered irritant when more than 5% of participants had a positive test per ST positivity criteria (wheal ≥3 mm than initial wheal and associated erythema of the same size or greater than wheal). We also compared our results with current guidelines. RESULTS A total of 187 participants (78% NMBA-tolerant) underwent 7812 skin tests. All undiluted SPT concentrations were nonirritant. We found the following maximal IDT NICs (mg/mL): cisatracurium (0.02), rocuronium (0.05), succinylcholine (0.8), vecuronium (0.01), neostigmine (0.2), sugammadex (50), and S-R-Cx (sugammadex 7.14 + rocuronium 2). CONCLUSION Our results suggest that SPT may be performed with undiluted stock concentrations. We confirm maximal IDT NICs for cisatracurium and rocuronium. We also propose that currently recommended maximal IDT NICs of succinylcholine, neostigmine, sugammadex, and S-R-Cx could be increased, whereas the maximal IDT NIC of vecuronium could be decreased compared with current guidelines and prior reports.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla.
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Dan Morgenstern-Kaplan
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - W Tatiana Garzon-Siatoya
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Fla
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Baldo BA. Allergic and other adverse reactions to drugs used in anesthesia and surgery. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:16. [PMCID: PMC10264870 DOI: 10.1007/s44254-023-00018-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/02/2023] [Accepted: 04/11/2023] [Indexed: 11/13/2023]
Abstract
The list of drugs patients may be exposed to during the perioperative and postoperative periods is potentially extensive. It includes induction agents, neuromuscular blocking drugs (NMBDs), opioids, antibiotics, sugammadex, colloids, local anesthetics, polypeptides, antifibrinolytic agents, heparin and related anticoagulants, blue dyes, chlorhexidine, and a range of other agents depending on several factors related to individual patients’ clinical condition and progress in the postoperative recovery period. To avoid poor or ultrarapid metabolizers to a particular drug (for example tramadol and codeine) or possible adverse drug reactions (ADRs), some drugs may need to be avoided during or after surgery. This will be the case for patients with a history of anaphylaxis or other adverse events/intolerances to a known drug. Other drugs may be ceased for a period before surgery, e.g., anticoagulants that increase the chance of bleeding; diuretics for patients with acute renal failure; antihypertensives relative to kidney injury after major vascular surgery; and serotonergic drugs that together with some opioids may rarely induce serotonin toxicity. Studies of germline variations shown by genotyping and phenotyping to identify a predisposition of genetic factors to ADRs offer an increasingly important approach to individualize drug therapy. Studies of associations of human leukocyte antigen (HLA) genes with some serious delayed immune-mediated reactions are ongoing and variations of drug-metabolizing cytochrome CYP450 enzymes, P-glycoprotein, and catechol-O -methyltransferase show promise for the assessment of ADRs and non-responses to drugs, particularly opioids and other analgesics. Surveys of ADRs from an increasing number of institutions often cover small numbers of patients, are retrospective in nature, fail to clearly identify culprit drugs, and do not adequately distinguish immune-mediated from non-immune-mediated anaphylactoid reactions. From the many surveys undertaken, the large list of agents identified during and after anesthesia and surgery are examined for their ADR involvement. Drugs are classified into those most often involved, (NMBD and antibiotics); drugs that are becoming more frequently implicated, namely antibiotics (particularly teicoplanin), and blue dyes; those becoming less frequently involved; and drugs more rarely involved in perioperative, and postoperative adverse reactions but still important and necessary to keep in mind for the occasional potential sensitive patient. Clinicians should be aware of the similarities between drug-induced true allergic type I IgE/FcεRI- and pseudoallergic MRGPRX2-mediated ADRs, the clinical features of each, and their distinguishing characteristics. Procedures for identifying MRGPRX2 agonists and diagnosing and distinguishing pseudoallergic from allergic reaction mechanisms are discussed.
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Affiliation(s)
- Brian A. Baldo
- Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney, St Leonards, Australia
- Department of Medicine, University of Sydney, Sydney, NSW Australia
- Lindfield, Australia
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Hung SK, Yeh CC, Ting PC, Chen CH, Kao MC. Successful management of rocuronium-induced anaphylaxis with sugammadex: A case report. J Int Med Res 2022; 50:3000605221113913. [PMID: 35869623 PMCID: PMC9315254 DOI: 10.1177/03000605221113913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although anaphylaxis during anaesthesia is a rare event, neuromuscular
blocking drugs are responsible for 62% of anaesthesia-related
anaphylaxis. However, sugammadex, a modified gamma-cyclodextrin, can
encapsulate rocuronium molecules and cause the rapid reversal of the
neuromuscular blockade. A 68-year-old man who presented for a radical
prostatectomy was induced with IV fentanyl/propofol/rocuronium. He had
not received rocuronium previously but had received cisatracurium.
Shortly after anaesthesia, the patient’s heart rate abruptly
increased, and systolic blood pressure (SBP) dropped to 40 mm Hg.
Despite cardiopulmonary resuscitation and intensive management, his
haemodynamic stability did not improve until he received IV
sugammadex, 200 mg. Intradermal skin tests showed he was positive for
cisatracurium, rocuronium and succinylcholine. The patient was
suspected to have cross-reactivity of rocuronium with cisatracurium.
This case highlights the potential benefit of sugammadex as an adjunct
to conventional measures during rocuronium-induced anaphylaxis.
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Affiliation(s)
- Sheng-Kai Hung
- Department of Anaesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chia-Chi Yeh
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Pei-Chi Ting
- Department of Anaesthesiology, New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City, Taiwan
| | - Cay-Huyen Chen
- Department of Anaesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Ming-Chang Kao
- Department of Anaesthesiology, New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City, Taiwan.,Department of Anaesthesiology, New Taipei Municipal TuCheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist., New Taipei City, Taiwan
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5
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Lee HY, Jung KT. Advantages and pitfalls of clinical application of sugammadex. Anesth Pain Med (Seoul) 2020; 15:259-268. [PMID: 33329823 PMCID: PMC7713848 DOI: 10.17085/apm.19099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 12/18/2022] Open
Abstract
Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.
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Affiliation(s)
- Hyung Young Lee
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
| | - Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
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Ebo DG, Baldo BA, Van Gasse AL, Mertens C, Elst J, Sermeus L, Bridts CH, De Clerck LS, Sabato V. Reply to "Does sugammadex have multiple mechanisms for causing anaphylaxis?". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2458-2459. [PMID: 32620443 DOI: 10.1016/j.jaip.2020.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Didier G Ebo
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology and the Infla-Med Consortium of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium; Department of Immunology - Allergology, AZ Jan Palfijn Gent, Ghent, Belgium.
| | - Brian A Baldo
- Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney and Department of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Athina L Van Gasse
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology and the Infla-Med Consortium of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Science, Department of Pediatrics and the Infla-Med Consortium of Excellence, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Christel Mertens
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology and the Infla-Med Consortium of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Jessy Elst
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology and the Infla-Med Consortium of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Luc Sermeus
- Faculty of Medicine and Health Science, Department of Anesthesiology, University of Antwerp, Antwerp University Hospital, Antwerpen, Belgium
| | - Chris H Bridts
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology and the Infla-Med Consortium of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Luc S De Clerck
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology and the Infla-Med Consortium of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
| | - Vito Sabato
- Faculty of Medicine and Health Science, Department of Immunology - Allergology - Rheumatology and the Infla-Med Consortium of Excellence, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium; Department of Immunology - Allergology, AZ Jan Palfijn Gent, Ghent, Belgium
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7
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Ebo DG, Baldo BA, Van Gasse AL, Mertens C, Elst J, Sermeus L, Bridts CH, Hagendorens MM, De Clerck LS, Sabato V. Anaphylaxis to sugammadex-rocuronium inclusion complex: An IgE-mediated reaction due to allergenic changes at the sugammadex primary rim. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1410-1415.e3. [DOI: 10.1016/j.jaip.2019.11.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/26/2019] [Accepted: 11/05/2019] [Indexed: 11/15/2022]
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10
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Baldo BA. Anaphylaxis caused by sugammadex- rocuronium inclusion complex: What is the basis of the allergenic recognition? J Clin Anesth 2019; 54:48-49. [DOI: 10.1016/j.jclinane.2018.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/23/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022]
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Kim GH, Choi WS, Kim JE, Yun MJ, Koo MS, Kwon M, Seo H. Anaphylactic shock after sugammadex administration, induced by formation of a sugammadex-rocuronium complex -a case report. Korean J Anesthesiol 2018; 72:495-499. [PMID: 30481948 PMCID: PMC6781209 DOI: 10.4097/kja.d.18.00232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background Sugammadex is a reversal agent for non-depolarizing neuromuscular blockers and widely used worldwide on account of its rapid and effective reversal from neuromuscular blockade, despite its advantages, multiple cases of sugammadex-induced anaphylactic shock have been reported. Case A 42-year-old man developed anaphylactic shock in the postanesthesia care unit. Initially, sugammadex was suspected as the causative agent, but an intradermal skin test revealed negative results. A further skin test was performed with sugammadex-rocuronium complex that yielded positive results. Conclusions Anesthesiologists and healthcare providers should be aware of the possibility of anaphylaxis from the sugammadex-rocuronium complex, as well as from sugammadex or rocuronium alone.
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Affiliation(s)
- Gunn Hee Kim
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Won Seop Choi
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Ji Eun Kim
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Mi Jung Yun
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Min Seok Koo
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Miyoung Kwon
- Department of Anesthesiology and Pain Medicine, National Medical Center, Seoul, Korea
| | - Hyungseok Seo
- Department of Anesthesiology and Pain Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
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Tadokoro F, Morita K, Michihata N, Fushimi K, Yasunaga H. Association between sugammadex and anaphylaxis in pediatric patients: A nested case-control study using a national inpatient database. Paediatr Anaesth 2018; 28:654-659. [PMID: 29947043 DOI: 10.1111/pan.13401] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sugammadex is used as a reversal drug during anesthesia. Although several case reports have described anaphylaxis following sugammadex infusion, little is known about the relationship between sugammadex and anaphylaxis, particularly in pediatric patients. AIMS The aim of this retrospective study was to investigate the association between sugammadex and in-hospital anaphylaxis in pediatric patients who underwent general anesthesia. METHODS We identified patients who underwent general anesthesia in a Japanese national inpatient database between July 2010 and March 2016. We conducted 1-4 case-control matching between patients with and without perioperative anaphylaxis. We calculated the adjusted odds ratio for sugammadex use and occurrence of anaphylaxis, using a conditional logistic regression analysis with adjustment for duration of anesthesia, antibiotics, and blood transfusions. RESULTS Among 835 405 patients who underwent general anesthesia, we identified 149 (0.018%) patients with anaphylactic shock and 472 (0.056%) with a combination of anaphylaxis associated signs/symptoms and skin lesions. Sugammadex use was not significantly associated with anaphylactic shock (odds ratio, 0.80; 95% confidence interval, 0.53-1.21; P = .29) or the combination of anaphylaxis associated signs/symptoms and skin lesions (odds ratio, 1.25; 95% confidence interval, 0.97-1.60; P = .08). CONCLUSION The present study showed no significant association between sugammadex and perioperative anaphylaxis in pediatric patients who underwent general anesthesia.
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Affiliation(s)
- Fumino Tadokoro
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kojiro Morita
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Yamaoka M, Deguchi M, Ninomiya K, Kurasako T, Matsumoto M. A suspected case of rocuronium-sugammadex complex-induced anaphylactic shock after cesarean section. J Anesth 2016; 31:148-151. [PMID: 27853881 PMCID: PMC5288440 DOI: 10.1007/s00540-016-2280-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/02/2016] [Indexed: 12/19/2022]
Abstract
An anaphylactic reaction during a cesarean section occurs rarely, and rocuronium is thought to be one of the common agents causing perioperative anaphylaxis. Here we report an anaphylactic shock after cesarean section that is suggested to be induced by the rocuronium-sugammadex complex. A 36-year-old primigravida underwent an elective cesarean section under general anesthesia due to placenta previa. While the operation was completed uneventfully, she developed anaphylactic shock following sugammadex administration. She was successfully managed with rapid treatments. Serum tryptase level was significantly elevated. Although sugammadex was first suspected to be the causative agent, the result of intradermal skin tests with sugammadex were negative. Surprisingly, a subsequent intradermal test with undiluted rocuronium caused the patient to fall into a state of shock. Furthermore, a later skin-prick test with pre-mixed rocuronium-sugammadex complex also revealed a strong positive reaction, and a test with only rocuronium showed negative. We finally concluded that the rocuronium-sugammadex complex is the causative agent in this case. To the best of our knowledge, this is the first report suggesting anaphylaxis caused by the rocuronium-sugammadex complex. This case highlights the importance of appropriate examinations to determinate the pathogenesis of anaphylaxis in order to establish risk reduction strategies.
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Affiliation(s)
- Masakazu Yamaoka
- Department of Anesthesiology, Japanese Red Cross Society Himeji Hospital, 1-12-1, Shimoteno, Himeji, Japan.
| | - Miki Deguchi
- Department of Anesthesiology, Japanese Red Cross Society Himeji Hospital, 1-12-1, Shimoteno, Himeji, Japan
| | - Kiichiro Ninomiya
- Department of Allergy and Respiratory Medicine, Okayama University Hospital, Okayama, Japan
| | - Toshiaki Kurasako
- Department of Anesthesiology, Japanese Red Cross Society Himeji Hospital, 1-12-1, Shimoteno, Himeji, Japan
| | - Mutsuko Matsumoto
- Department of Anesthesiology, Japanese Red Cross Society Himeji Hospital, 1-12-1, Shimoteno, Himeji, Japan
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Ho G, Clarke RC, Sadleir PHM, Platt PR. The First Case Report of Anaphylaxis Caused by the Inclusion Complex of Rocuronium and Sugammadex. ACTA ACUST UNITED AC 2016; 7:190-192. [DOI: 10.1213/xaa.0000000000000382] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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15
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Schaller SJ, Lewald H. Clinical pharmacology and efficacy of sugammadex in the reversal of neuromuscular blockade. Expert Opin Drug Metab Toxicol 2016; 12:1097-108. [DOI: 10.1080/17425255.2016.1215426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Stefan Josef Schaller
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Heidrun Lewald
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Hotta E, Tamagawa-Mineoka R, Masuda K, Taura M, Nakagawa Y, Kanehisa F, Tashima S, Katoh N. Anaphylaxis caused by γ-cyclodextrin in sugammadex. Allergol Int 2016; 65:356-8. [PMID: 27062217 DOI: 10.1016/j.alit.2016.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 02/24/2016] [Accepted: 02/28/2016] [Indexed: 12/20/2022] Open
Affiliation(s)
- Eri Hotta
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Risa Tamagawa-Mineoka
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Koji Masuda
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Maiko Taura
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuka Nakagawa
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fuminao Kanehisa
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Saki Tashima
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Norito Katoh
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Spoerl D, D'Incau S, Roux-Lombard P, Harr T, Czarnetzki C. Non-IgE-Dependent Hypersensitivity to Rocuronium Reversed by Sugammadex: Report of Three Cases and Hypothesis on the Underlying Mechanism. Int Arch Allergy Immunol 2016; 169:256-62. [PMID: 27240836 DOI: 10.1159/000446182] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/12/2016] [Indexed: 11/19/2022] Open
Abstract
We present 3 cases of pseudoallergic (anaphylactoid) reactions to perioperatively administered rocuronium, which rapidly resolved after sugammadex injection. Allergological workup showed no evidence for immediate-type hypersensitivity to the drugs used for anesthesia, including rocuronium. However, rocuronium induced an irritative reaction in skin tests in all 3 patients and in 3 healthy individuals. This reaction was specifically suppressed by adding sugammadex at a 1:1 molecular proportion to rocuronium before the skin tests. This observation suggests that the patients suffered from a pseudoallergic reaction, and indicates that sugammadex might act via the inhibition of non-IgE mediated MRGPRX2 (Mas-related G-protein-coupled receptor member X2)-triggered mast cell degranulation induced by rocuronium.
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Affiliation(s)
- David Spoerl
- Division of Clinical Immunology and Allergy, Department of Medical Specialties, Geneva University Hospital, Geneva, Switzerland
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18
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Yamada Y, Yamamoto T, Tanabe K, Fukuoka N, Takenaka M, Iida H. A case of anaphylaxis apparently induced by sugammadex and rocuronium in successive surgeries. J Clin Anesth 2016; 32:30-2. [PMID: 27290941 DOI: 10.1016/j.jclinane.2015.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 11/12/2015] [Indexed: 11/24/2022]
Abstract
Rocuronium is the agent most frequently involved in perioperative anaphylaxis, and sugammadex has also been known to induce anaphylactic reactions. We describe a case of successive anaphylactic episodes that seemed to be induced by clinical doses of rocuronium and sugammadex. The patient was a 19-year-old woman who had a medical history of asthma, but no history of surgery. She had been injured in a fall, and several surgeries were scheduled for multiple bone fractures. At the first surgery under general anesthesia, she developed anaphylaxis 5 min after sugammadex administration. A second general anesthesia for treatment of calcaneal fracture was induced uneventfully without neuromuscular blockade after 10 days. A third general anesthesia was scheduled to reinforce the spinal column 12 days after the first surgery. She developed anaphylaxis 8 min after rocuronium administration. The level of plasma histamine was elevated, but serum tryptase level remained normal. This surgery was canceled and rescheduled without use of a neuromuscular blockade. Skin tests were performed in a later investigation. The patient showed positive results on intradermal tests for sugammadex and rocuronium, supporting a diagnosis of allergic reactions to both drugs. Clinicians must be aware that anaphylactic reactions can be induced by both sugammadex and rocuronium.
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Affiliation(s)
- Yuko Yamada
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan.
| | - Takuji Yamamoto
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Kumiko Tanabe
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Naokazu Fukuoka
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Motoyasu Takenaka
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
| | - Hiroki Iida
- Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu 501-1194, Japan
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19
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Takazawa T, Mitsuhata H, Mertes PM. Sugammadex and rocuronium-induced anaphylaxis. J Anesth 2015; 30:290-7. [PMID: 26646837 PMCID: PMC4819478 DOI: 10.1007/s00540-015-2105-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/11/2015] [Indexed: 12/19/2022]
Abstract
Perioperative anaphylaxis is a life-threatening clinical condition that is typically the result of drugs or substances used for anesthesia or surgery. The most common cause of anaphylaxis during anesthesia is reportedly neuromuscular blocking agents. Of the many muscle relaxants that are clinically available, rocuronium is becoming popular in many countries. Recent studies have demonstrated that succinylcholine (but also rocuronium use) is associated with a relatively high rate of IgE-mediated anaphylaxis compared with other muscle relaxant agents. Sugammadex is widely used for reversal of the effects of steroidal neuromuscular blocking agents, such as rocuronium and vecuronium. Confirmed cases of allergic reactions to clinical doses of sugammadex have also been recently reported. Given these circumstances, the number of cases of hypersensitivity to either sugammadex or rocuronium is likely to increase. Thus, anesthesiologists should be familiar with the epidemiology, mechanisms, and clinical presentations of anaphylaxis induced by these drugs. In this review, we focus on the diagnosis and treatment of anaphylaxis to sugammadex and neuromuscular blocking agents. Moreover, we discuss recent studies in this field, including the diagnostic utility of flow cytometry and improvement of rocuronium-induced anaphylaxis with the use of sugammadex.
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Affiliation(s)
- Tomonori Takazawa
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511, Japan.
| | - Hiromasa Mitsuhata
- Department of Anesthesiology, Juntendo Tokyo Koto Geriatric Medical Center, 3-3-20 Shinsuna, Koto-Ku, Tokyo, 136-0075, Japan
| | - Paul Michel Mertes
- Service d'anesthésie-réanimation chirurgicale, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP 426, 67091, Strasbourg Cedex, France
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20
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Oliveri V, Bellia F, Pietropaolo A, Vecchio G. Unusual Cyclodextrin Derivatives as a New Avenue to Modulate Self- and Metal-Induced Aβ Aggregation. Chemistry 2015; 21:14047-59. [PMID: 26298549 DOI: 10.1002/chem.201502155] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Indexed: 12/19/2022]
Abstract
Mounting evidence suggests an important role of cyclodextrins in providing protection in neurodegenerative disorders. Metal dyshomeostasis is reported to be a pathogenic factor in neurodegeneration because it could be responsible for damage involving oxidative stress and protein aggregation. As such, metal ions represent an effective target. To improve the metal-binding ability of cyclodextrin, we synthesized three new 8-hydroxyquinoline-cyclodextrin conjugates with difunctionalized cyclodextrins. In particular, the 3-difunctionalized regioisomer represents the first example of cyclodextrin with two pendants at the secondary rim, resulting in a promising compound. The derivatives have significant antioxidant capacity and the powerful activity in inhibiting self-induced amyloid-β aggregation seems to be led by synergistic effects of both cyclodextrin and hydroxyquinoline. Moreover, the derivatives are also able to complex metal ions and to inhibit metal-induced protein aggregation. Therefore, these compounds could have potential as therapeutic agents in diseases related to protein aggregation and metal dyshomeostasis.
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Affiliation(s)
- Valentina Oliveri
- Dipartimento di Scienze Chimiche, Università di Catania, Viale A. Doria 6, 95125, Catania (Italy).,Consorzio Interuniversitario di Ricerca in Chimica dei Metalli nei Sistemi Biologici, C.I.R.C.M.S.B, Unità di Ricerca di Catania, 95125 Catania (Italy)
| | - Francesco Bellia
- Istituto di Biostrutture e Bioimmagini, CNR, Via P. Gaifami 18, 95126 Catania, Italy
| | - Adriana Pietropaolo
- Dipartimento di Scienze della Salute, Università di Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - Graziella Vecchio
- Dipartimento di Scienze Chimiche, Università di Catania, Viale A. Doria 6, 95125, Catania (Italy).
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21
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Baldo BA, McDonnell NJ. Sugammadex and anaphylaxis in the operating theater. ACTA ACUST UNITED AC 2014; 61:239-45. [PMID: 24666509 DOI: 10.1016/j.redar.2014.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 02/19/2014] [Indexed: 10/25/2022]
Affiliation(s)
- B A Baldo
- Retired. Formerly, Head, Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney and Department of Medicine, University of Sydney, Sydney, NSW, Australia.
| | - N J McDonnell
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women and School of Women's and Infants' Health and School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
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22
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IgE and Drug Allergy: Antibody Recognition of ‘Small’ Molecules of Widely Varying Structures and Activities. Antibodies (Basel) 2014. [DOI: 10.3390/antib3010056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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23
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Kim SY, Choi GS, Kim HK, Kim JH, Kim CS, Yang JW, You GI, Lee JY. Delayed onset urticaria and angioedema caused by components of itraconazole solution. ALLERGY ASTHMA & RESPIRATORY DISEASE 2014. [DOI: 10.4168/aard.2014.2.2.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Soo-Young Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Gil-Soon Choi
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Hee-Kyoo Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Je Hun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Cheol Su Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Joung Wook Yang
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Ga In You
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jin Young Lee
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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24
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Gamal-Eldin MA, Macartney DH. Cucurbit[7]uril host-guest complexes and [2]pseudorotaxanes with N-methylpiperidinium, N-methylpyrrolidinium, and N-methylmorpholinium cations in aqueous solution. Org Biomol Chem 2013; 11:1234-41. [PMID: 23314170 DOI: 10.1039/c2ob27282b] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The formations of host-guest complexes between cucurbit[7]uril and a series of N-substituted N-methylpiperidinium, N-methylpyrrolidinium, and N-methylmorpholinium cations in aqueous solution have been investigated using (1)H NMR spectroscopy and electrospray ionization mass spectrometry. Dications comprising the N-methylheterocyclic head groups, bridged by a decamethylene chain, form sequential 1 : 1 ([2]pseudorotaxanes) and 2 : 1 host-guest complexes with cucurbit[7]uril. The cucurbituril initially resides over the decamethylene chain, however with further additions of the host molecule a translocation of the hosts to the cationic N-heterocyclic head groups occurs. The order of the magnitude of the cucurbituril host-guest stability constants, determined by competitive (1)H NMR binding experiments, follows the trend in the hydrophobicity of the quaternary ammonium cations.
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Affiliation(s)
- Mona A Gamal-Eldin
- Department of Chemistry, Queen's University, 90 Bader Lane, Kingston, ON K7L 3N6, Canada
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25
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Schaller SJ, Fink H. Sugammadex as a reversal agent for neuromuscular block: an evidence-based review. CORE EVIDENCE 2013; 8:57-67. [PMID: 24098155 PMCID: PMC3789633 DOI: 10.2147/ce.s35675] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Sugammadex is the first clinical representative of a new class of drugs called selective relaxant binding agents. It has revolutionized the way anesthesiologists think about drug reversal. Sugammadex selectively binds rocuronium or vecuronium, thereby reversing their neuromuscular blocking action. Due to its 1:1 binding of rocuronium or vecuronium, it is able to reverse any depth of neuromuscular block. So far, it has been approved for use in adult patients and for pediatric patients over 2 years. Since its approval in Europe, Japan, and Australia, further insight on its use in special patient populations and specific diseases have become available. Due to its pharmacodynamic profile, sugammadex, in combination with rocuronium, may have the potential to displace succinylcholine as the "gold standard" muscle relaxant for rapid sequence induction. The use of rocuronium or vecuronium, with the potential of reverse of their action with sugammadex, seems to be safe in patients with impaired neuromuscular transmission, ie, neuromuscular diseases, including myasthenia gravis. Data from long-term use of sugammadex is not yet available. Evidence suggesting an economic advantage of using sugammadex and justifying its relatively high cost for an anesthesia-related drug, is missing.
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Affiliation(s)
- Stefan Josef Schaller
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- Department of Anesthesia, Massachusetts General Hospital, Boston, MA, USA
| | - Heidrun Fink
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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26
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Arshad SH, Dharmage SC, Ferreira F, Fixman ED, Gadermaier G, Hauser M, Sampson AP, Teran LM, Wallner M, Wardlaw AJ. Developments in the field of allergy in 2011 through the eyes of Clinical and Experimental Allergy. Clin Exp Allergy 2013. [PMID: 23181787 DOI: 10.1111/cea.12037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As in previous years, we felt it would be of value to our readership to summarize the new information provided by the authors who have published in Clinical and Experimental Allergy in 2011 and set this in the context of recent advances in our understanding of the pathogenesis and management of allergic disease in all its many manifestations. In 2011, about 210 articles were published in Clinical and Experimental Allergy including editorials, reviews, opinion articles, guidelines, letters, book reviews and of course at the heart of the journal, papers containing original data. As before, this review is divided into sections based on the way the journal is structured, although this year we have grouped together all the papers dealing with mechanisms of allergic disease, whether they involve patients (clinical mechanisms), pure in vitro studies (basic mechanisms) or animal models (experimental models), as we felt this was a more coherent way to deal with the subject. In the field of asthma and rhinitis, the relationship between airway inflammation and airway dysfunction was of perennial interest to investigators, as were phenotypes and biomarkers. Aspirin hypersensitivity appeared in studies in several papers and there was new interest in asthma in the elderly. The mechanisms involved in allergic disease describe advances in our understanding of T cell responses, the relationship between inflammation and disease, mast cell and basophil activation, steroid resistance and novel therapies. In the section dealing with epidemiology, studies seeking to identify risk factors for allergic disease including vitamin D are prominent, as once again are studies investigating gene-environment interactions. The clinical allergy section focuses on drug allergy, food allergy and immunotherapy. The area of oral immunotherapy for food allergy is well covered and we were grateful to Stephen Durham for guest editing an outstanding special issue on immunotherapy in the centenary year of Leonard Noon's pioneering work. Lastly, in the field of allergens, the interest in component-resolved diagnosis continues to grow and there are also articles describing important novel cultivars and the effect of food processing on the allergenic properties of foods. Another terrific year, full of important and high-quality work,which the journal has been proud to bring to the allergy community.
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Affiliation(s)
- S H Arshad
- David Hide Asthma and Allergy Research Centre, Isle of Wight, UK
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27
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Motamed C, Baguenard P, Bourgain JL. Possible mitigation of rocuronium-induced anaphylaxis after administration of sugammadex. J Anaesthesiol Clin Pharmacol 2012; 28:127-8. [PMID: 22345962 PMCID: PMC3275947 DOI: 10.4103/0970-9185.92464] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Cyrus Motamed
- Service d'anesthésie Institut Gustave Roussy. Villejuif France. Rue Edouard Vaillant villejuif, France
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28
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Hypersensitivity reactions in the anesthesia setting/allergic reactions to anesthetics. Curr Opin Allergy Clin Immunol 2012; 12:361-8. [DOI: 10.1097/aci.0b013e328355b82f] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Abad Gurumeta A, Gutiérrez García R. [Sugammadex: the last shot for anaphylactic shock due to rocuronium?]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:177-179. [PMID: 22575774 DOI: 10.1016/j.redar.2012.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/21/2012] [Indexed: 05/31/2023]
Affiliation(s)
- A Abad Gurumeta
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España
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30
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Kalkan Y, Tümkaya L, Bostan H, Tomak Y, Yılmaz A. Effects of sugammadex on immunoreactivity of calcineurin in rat testes cells after neuromuscular block: a pilot study. J Mol Histol 2011; 43:235-41. [DOI: 10.1007/s10735-011-9384-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 12/17/2011] [Indexed: 12/17/2022]
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